Executive Summary
- Consumption of iron supplements by pregnant women
- Dietary diversity for women, with emphasis on food sources of iron and foods that enhance iron absorption
- Dietary diversity for children 6–23 months, with emphasis on food sources of iron and vitamin A and foods that enhance iron absorption
- Optimal meal frequency for children 6–23 months of age
- Early initiation of breastfeeding
- Exclusive breastfeeding from birth through the first six months
- Timely introduction of appropriate complementary foods
- Reduction in the consumption of foods of low-nutrient value (junk food)
- Presumptive treatment for helminths for pregnant women and young children
- Handwashing at three out of five critical times (after using the latrine, after changing a baby’s diaper/cleaning a child, before preparing food, before feeding a child, and before eating)
- Adoption of methods for safe and prolonged storage of nutrient-dense produce for the winter1
SPRING operated primarily in four rayons (districts) and seven townships of Jalalabad oblast (province), five rayons and one township of Naryn oblast, and health facilities in Bishkek. SPRING’s approach focused on building capacity in nutrition among health workers in the above areas; community outreach through a network of community activists to reach households through household visits and community events; support to the Baby-Friendly Hospital Initiative (BFHI) in 16 hospitals and 11 Family Medicine Centers; promoting better nutrition through mass media and social media; and national-level policy work.
This report summarizes findings from an endline survey carried out in February–March 2017, among 1,359 women in Jumgal district in Naryn oblast, parts of Jalalabad oblast, and Uzgen in Osh oblast. Results are compared against those of a baseline survey carried out in October–November 2014, and two streamlined surveys on dietary diversity that were carried out in late winte/early spring of 2015 and 2016. SPRING also carried out two rounds of qualitative research to complement the four surveys. The first was in 2016, conducted to explore reasons for unexpected increases in consumption of certain fresh fruits and vegetables during winter months, and the second was in 2018, and aimed to investigate causes of low levels of handwashing and child feeding that were seen in the endline survey. Select results from the qualitative research are provided where appropriate.
Overall, results of the endline survey showed that many key nutrition practices improved significantly between baseline and endline. Notable results included the following.
Iron during pregnancy. Many indicators related to anemia prevention and iron supplementation during pregnancy improved significantly between surveys. Women in intervention areas reported making more antenatal clinic (ANC) visits during their most recent pregnancy and made the visits earlier in the pregnancy. The percentage of women who said they discussed iron during pregnancy during their visits increased from 55 percent to 78 percent in Jalalabad; 20 percent to 73 percent in Naryn; and 49 percent to 59 percent in Uzgen. The increase in both intervention areas was significantly greater than in the comparison region. More women reported receiving and taking iron during pregnancy, and a greater percentage said that the formulation was iron–folic acid (IFA), which is the formulation of iron supplementation promoted by SPRING. Most importantly, the percentage of women who reported taking iron for 90 or more days almost doubled, rising from 16 percent to 31 percent in intervention areas, compared to a smaller increase in Uzgen. These positive results suggest that SPRING interventions likely had a positive effect on this important nutrition practice.
Women’s dietary diversity. Several aspects of women’s diet also improved significantly between surveys. Of note, the percentage of women consuming foods from five or more food groups in the previous 24 hours increased from 38 percent at baseline to 71 percent at endline. Especially encouraging was that the increase was driven by greater consumption of the most nutrient-rich food groups, especially dark green leafy vegetables, vitamin A–rich fruits and vegetables, and legumes, seeds, and nuts. The results are impressive because the baseline took place soon after the harvest season of October–November, while the endline took place in the middle of winter, in February–March. Interestingly, dietary diversity improved almost as much in Uzgen as in the intervention areas. Qualitative research provided some insights as to why dietary diversity increased even during winter months, including better awareness of the importance of nutritious foods throughout the year, storing a wider variety of foods, and the fact that foods are widely available in local markets, even in winter. The magnitude of the improvements suggests that SPRING probably had some impact in this area, perhaps with spillover to Uzgen from nearby Jalalabad or due to national efforts. However, because of substantial improvements in the comparison area, it is not possible to attribute all of the improvements to SPRING. In any case, the strong improvement seen in this nutrition practice is a positive and welcome result for women in all three regions.
Infant and young child feeding—breastfeeding. SPRING measured several infant and young child feeding (IYCF) indicators in this survey, including early initiation of breastfeeding and provision of colostrum, current breastfeeding and continued breastfeeding at two years, and exclusive breastfeeding for children 0–5 months. Breastfeeding is very widely practiced in the Kyrgyz Republic, so most indicators were at high levels at baseline and remained high at endline. The most notable improvement came with exclusive breastfeeding. In intervention areas, the percentage of babies being exclusively breastfed increased from 29 percent to 63 percent between surveys, significantly more than the improvement in Uzgen (which rose from 37 percent to 51 percent). This is a notable result where SPRING appears to have had positive impact on an important nutrition practice.
Infant and young child feeding—diet of children aged 6–23 months. Other IYCF indicators measured included appropriate introduction of complementary foods for children aged 6–8 months, and dietary diversity, feeding frequency, and minimum acceptable diet (MAD) for children aged 6–23 months. Results were mixed with these indicators. With regard to the appropriate introduction of complementary foods, levels were very high at baseline and experienced mostly small improvements between baseline and endline. The main aspect that changed was that premature introduction of complementary foods (before six months) decreased dramatically in both SPRING intervention areas, falling from 67 percent down to 18 percent in Naryn, and from 35 percent to 14 percent in Jalalabad. In Uzgen, the percentage declined only slightly, dropping from 32 percent to 28 percent, suggesting that SPRING interventions may have influenced mothers to delay introducing solid and semi-solid foods until their child reaches six months.
Changes in diet for children aged 6–23 months painted a mixed picture. Overall, SPRING appears to have had a positive effect on children’s dietary diversity, which increased significantly, from 42 percent to 54 percent, between surveys, whereas it decreased slightly in Uzgen. However, improvement in the SPRING intervention areas was due almost entirely to improvements among non-breastfed children in Naryn. Dietary diversity actually declined in Jalalabad (figures not shown separately in table 1). Feeding frequency declined between surveys in all three regions. Qualitative research carried out after the endline survey established some possible reasons for declines; some were due to seasonality and cold climate. Some focus group discussion (FGD) participants mentioned that the composition of children’s diets changes in the winter, with larger portions and foods such as meats and pasta that are more filling, resulting in fewer needed feedings. Because of these mixed results the composite indicator of MAD was nearly unchanged in intervention areas, and declined from 32 percent to 26 percent in Uzgen.
One positive note is that SPRING seems to have had an impact on consumption of junk food (sweet/sugary and processed foods) among the youngest children (0–5 months). In intervention areas, junk food consumption declined from 15 percent to 8 percent among that age group, a significantly better peformance than in the comparison area, where it increased from 6 percent to 10 percent. Results suggest that SPRING may be making some gains in getting mothers to avoid feeding very young children non-nutritious foods, in the face of trends going the opposite way in the Kyrgyz Republic and in many parts of the world.
Source of foods. The study looked at where women obtained the foods that they ate. Because of different climate and topography, there were some regional differences in the kinds of foods grown on farms and available in local markets. Over 20 different fruits and vegetables were mentioned as being grown on farms at some point during the year. In Jalalabad, potatoes, tomatoes, apples, carrot, cabbage, and dark green leafy vegetables were reported most often as grown on farms (30–38 percent of responses), while in Naryn, the main crops grown were potatoes, carrots, cabbage, jusai, and other dark green leafy vegetables (34–62 percent of responses). Respondents reported that a wide variety of foods was available in local markets, even in winter. In Naryn, 11 foods were mentioned by at least 50 percent of respondents as being currently available if they needed them, while in Jalalabad, 15 foods were mentioned by at least 50 percent. Most foods were more apt to be available in Jalalabad than in either Naryn or Uzgen. Some of these results (fewer women saying they grew foods on farms and more market availability) were likely influenced by the fact that the Jalalabad sample was more urban.
Food storage and preservation. Results were mixed with regard to these practices. For the most part, the percentage of households storing and preserving foods was quite high across all surveys, in most cases decreasing slightly between baseline and endline. Encouragingly, the mean number of foods that people store or preserve increased in most regions across surveys. A large majority of women reported still having at least some stored/preserved foods left at the time of the endline survey.
WASH (water, sanitation, and hygiene). SPRING’s scope of work did not include infrastructure improvements related to drinking water and sanitation. Little or no change was seen in those indicators between surveys. Reported practice of handwashing unfortunately declined significantly in all three regions. Qualitative research revealed that there are many reasons why people wash hands less often during the winter (endline) compared with warmer months (baseline). Among the main reasons were that outside water freezes, and also that people spend less time outside with animals during winter, there is less outside employment, and washing hands in cold water causes them to get dry and have cracked skin. Declines in reported practices in SPRING areas were not as severe as declines in Uzgen, so SPRING may have had some positive effect on the practice, though because the baseline and endline seasons were different, it is not possible to say with certainty.
Exposure to SPRING messages. The survey asked what nutrition messages respondents had heard, and from where. It also asked a series of knowledge questions to see how well people understood select basic nutrition concepts. One interesting finding was that 39 percent of women in the comparison area of Uzgen reported that they had heard of SPRING, which could indicate some benefits from regional and national-level work through mass media, social media, and policy work through the health system, or possibly spillover from SPRING’s work in nearby Jalalabad. Large majorities of respondents said they had heard nutrition messages on various topics, and the main source for most messages was health facilities.
In terms of basic knowledge of nutrition concepts, most respondents answered correctly about correct timing for exclusive breastfeeding and complementary feeding, with a greater degree of correct knowledge on exclusive breastfeeding in Jalalabad and Naryn than in Uzgen. Knowledge of vitamin–A rich foods was low (19–38 percent) in all three regions, especially in Naryn (19 percent). Question wording asked for more specificity in the response on the vitamin A question and could therefore have caused high levels of of “don’t know” responses (23–41 percent). Significantly more women had heard of anemia in SPRING intervention areas than in Uzgen, and women’s knowledge of both anemia and hygiene was also higher in SPRING areas than in Uzgen. Knowledge of women’s nutrition during pregnancy was low in all regions but was lower in intervention areas than in the comparison zone.
Overall, results of the endline survey were very positive, showing improvements in many key nutrition practices over the course of SPRING’s work. Of note, results suggest that SPRING had significant positive impact on iron supplementation during pregnancy, women’s diet, exclusive breastfeeding, and junk food consumption among young children. Results on children’s diet, food storage and preservation, and WASH were mixed, with both positive and negative or neutral results. Finally, even for those indicators where results improved significantly, in some cases the percentage of women reporting healthy practices was low. For example, despite significant improvements in women taking iron during pregnancy, with the percentage of women who took iron for at least 90 days nearly doubling, only 31 percent at endline reported taking it for 90-plus days, so there is still substantial room for improvement. Similarly, although women’s dietary diversity improved significantly, reported absolute consumption levels of several nutrient-rich foods remains low.
In sum, results show many impressive nutrition outcomes in the areas where SPRING worked, but there still areas for further improvement. Key indicators across all surveys are shown in Table 1.1 below.
Recommendations
The positive results from this survey suggest that SPRING’s overall approach was successful and should be continued in future programs and expanded to other oblasts as feasible. This includes building capacity in the health system, using community outreach, advocating for improved nutrition policies, and using various types of media, including social media, to widen the reach of nutrition messaging. The first recommendation, therefore, suggests continuity, while the ones that follow seek to make improvements in areas that did not experience improvement in this series of surveys.
- Explore ways to continue SPRING activities in project areas, and where possible expand to new areas. This is especially true for topical areas such as iron supplementation and women’s diet where, despite improvements, levels of good practice remain low.
- Continue existing interventions and develop new and innovative ones to address areas that did not improve and where levels of good practices are low. These include handwashing, feeding frequency, introducing complementary foods only after six months, continued breastfeeding among children older than 16 months, nutrition during pregnancy, and certain aspects of WASH and food storage/ preservation.
- Consider the role of seasons in future programs. SPRING initially thought that the winter season would mainly affect dietary diversity (and affect it negatively), but these surveys suggest something very different—that women’s dietary diversity may actually rise under some circumstances during winter, and winter may have a greater effect on aspects such as handwashing and possibly feeding frequency. Future programs could explore ways to overcome barriers to improving certain practices, especially by giving consideration to how changes in the practice could vary in different seasons throughout the year.
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